COM M E N T AR Y Open Access Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest John A Stewart Abstract Time to first defibrillation is widely accepted to correlate closely with survival and recovery of neurological function after cardiac arrest due to ventricular fibrillation or ventricular tachycardia. Focused training of a cadre of nurses to defibrillate on their own initiative may significantly decrease time to first defibrillation in cases of in-hospital cardiac arrest outside of critical care units. Such a program may be the best single strategy to improve in-hospital survival, simply and at reasonable cost. Introduction Survival from in-hospital cardiac arrest has not improved over the half-centur y since the advent of basic cardiopul- monary resuscitation (CPR) and defibrillation [1,2]. Sur- vival rates re main about 18% at best, and surv ival is lower on general units than in critical-care areas [3]. Explanations for this lack of progress often invoke co- morbidity, [2] and proposals for change have frequently focused on preventing p resumably futile resuscitation attempts by means of do-not-resuscitate orders [4]. Medical emergency teams have increasin gly been imple- mented to respond to early signs of deterioration and prevent progression to cardiac arrest [5]. But tachyar- rythmic arrests (ventricular fibrillation (VF) and ventri- cular tachycardia (VT)) are typically sudden, and this subset of arrests comprises the cases with a real chance of survival–if defibrillatio n is accomplished quickly. The most important change in out-of-hospital resuscitation over the past quarter-century has been the renewed focus on early defibrillation by first responders, and the best approach to improving in-hospital survival may be simply to bring effective early defibrillation into the hos- pital [6]. Organizing and deliverin g the full range of advanced car diovascular life support (ACLS) treatments with code teams is an expensive, complex, and daunting undertaking [7] that has little relation to outcomes–because survival for presenting rhythms other than VF and VT is dismal, both outside and inside the hospital. A program focused on saving lives would look much different: it would devote resources to treatments with proven effectiveness (primar- ily early defibrillation), up to the point of clearly diminish- ing returns. To improve survival from in-hospital arrests, a more effective a pproach to in-hospi tal defibrillatio n is needed. Discussion A defibrillator originally was a large and cumbersome device which had to be moved from the critical care unit to arrests in o ther areas of the hospital. Trained emergency personnel were usually at the scene of an arrest by the time the defibrillator arrived. During the 1970s and 1980s there was a trend toward greater num- bers of more por table defibrillators in hospitals, and a defibrillator on every nursing unit is now the norm. But training did not keep pace with availability: In the mid- 1980s this author brought the p roblem of delayed in- hospital defibrillation to the attention of several people active in the American Heart Association’s (AHA) Emergency Cardiac Care programs, and in 1992 pub- lished a description of a nurse-defibrillation training program using manual defibrillators [8]. Later, those AHA-affiliated authors began addressing the issue but linked nurse defibrillati on closely with the purchase and use of automated external defibrillators (AEDs) [9]. The American Heart Association/International Liaison Correspondence: jastewart325@gmail.com Cascade Healthcare Services, Seattle, Washington Full list of author information is available at the end of the article Stewart Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:42 http://www.sjtrem.com/content/18/1/42 © 2010 Ste wart; licensee BioMed Central Ltd. This is an Open Access article distribute d under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/b y/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cite d. Committee on Resuscitation’s stance continues to be that AEDs are the key to achieving early defibrillation in hospitals [10]. The AHA’s promotion of AEDs for in-hospital use i s not well supported by present evidence [11]. A large recent study from Detroit, the best to date, showed no improvement in t ime to defibrillation or survival after hospital-wide introduction of AED-capable defibrillators, at a cost of $2 million [12]. In addition, serious concerns have been raised about AED technology in the past few years, centering on the requirement for a “hands-of f” period for rhythm a nalysis that has been shown to decrease survival [6]. Inaccurate time data presents another impediment to implementation of nurse-defibrillation programs bec ause the true extent of the delayed-def ibrillation problem is obscured. Studies based on data from the National Reg- ist ry of Cardiopulmonary Resuscitation (NRCPR) report median times of 0 minutes [1]. These time intervals, based on handwritten code records, are unrealistically short [13]. NRCPR researchers have recognized this, [14]butinaccuratetimedatacontinuetobereported with little or no reservation [15]–though the problem could be solved fairly simply [16]. Several factors, then–limitations of AED technology, unrealistically short time-interval data, and of course cost [13]–serve to impede hospitals in addressing the problem of delayed defibrillation. A recent article provided some counterbalance to these factors: the investigators reported that delayed in-hospital defibrillation was a rela- tively frequent problem and that it lowered survival, although again the extent of the problem was obscured by use of NRCPR data [17]. (A main recommendation in the accompanying editorial was to buy more AEDs [18].) In recent years, there has been much interest in the 3- phase model of VF arrest proposed by Weisfeldt and Becker, which posits that after about 4 minutes treat- ment may be improved by a period of basic CPR before defibrillation [19]. The model has no relevance f or in- hospital defibrillation because 1) the goal should be to defibrillate in less than 4 minutes (the AHA has estab- lished a benchmark of less than 3 minutes for all in-hos- pital arrests [20]), and 2) with multiple rescuers typically available, all hospital protocols call for basic CPR while the defibrillator is being brought to t he scene. There- fore, defibrillation at the earliest possible moment remains the best approach for in-hospital tachyarryth- mic arrests. Doing anything in the first moments of a code is emo- tionally difficult, but defib rillation is no more difficult than other tasks nur ses are expected to perform in codes; certainly it is easier than performing effective basic CPR. The main rationale f or AED use–the pre- sumed need for advanced rhythm identification skills with manual defibrillators–is without foundation: the basic distinction, between an organized monitor rhythm and a chaotic pattern, is easily learned [21]. Another barrier to rapid defibrillation is the presumed danger to caregivers in adm inistering a shock. However, dangers of defibrillation have long been overstated (no docu- mented deaths or serious injuries in over 50 years) and safety has been further improved by the use of hands- free pads [22]. The basic procedure of defibr illation, whether with manual defibrillators or AEDs, is both easy and safe. The real problem comes not from the inherent difficulty of the task, but from the conditions of perfor- mance. Defibrillation is necessarily per formed in a life- threatening situation, without warning and under intense time pressure [23]. Such stressors, in combina- tion with the rarity of the event for a particular care- giver, can cause a significant decreas e in skill. Demonstrating mastery in a single simulation in a class- room setting is not sufficient t o ensure adequate reten- tion and competent performance in an actual code. Clinical competence in defibrillation calls for overtrain- ing: requiring practice well beyond the first competent performance by repeated performance in simulations and to a higher standard than may be required in an actual code. This is analogous t o aspects of military training (e.g., disassembling and reassembling a rifle while blindfolded). Two- to three-hour sessions with four to five trainees in each session should be sufficient for this component of the training. Affective aspects of defibrillation training also make it advisable to select a group of highly motivated learners. Participants in an in-hospital defibrillation program will be committing themselves to training intensively and maintaining competence for long periods of time with- out actually using the skill–butwhencalleduponthey will be expected to perform quickly and competently under very stressful conditions [23]. This level of perso- nal commitment should not–and indeed, cannot–be expected of all nurses. But it is u nnecessary to train a ll nurses in a facilit y, and indeed it is inadvisable to do so: a select group of nurses can be trained that their first responsibility in a code is to initiate monitoring and defibrillation while other staff do CPR, thus avoiding the role confusion that is known to be a significant problem with code team performance [24]. It may be possible to rely mainly on volunteers, thereby increasing the prob- ability that training will succeed. The inherent emotional appeal of defibrillation–the very real prospect of restor- ing a patient’s life quickly, cleanly, and dramatically–can act as an inducement for volunteers as well as a power- ful source of motivation during training. In-hospital defibrillation training programs will have the capabili ty to conduct unannounced drills for Stewart Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:42 http://www.sjtrem.com/content/18/1/42 Page 2 of 4 practice and performance testing. Many hospitals use “mock codes” to practice all aspects of code response; these are fairly complex productions involving a good deal of planning and disruption of daily work routines. Drills for defibrillation training can be conducted much more simply–one learner at a time–and preserve the element of unexpectedness that is a critical condition of performance. Such drills should prove valuable, both as a stimulus for learning and as an evaluation tool. Each learner could be required to perform competently in a surprise simulation 2 to 4 weeks after training, thereby providing a more valid test, and the participants’ general foreknowledge of the surprise testing should reinforce the training by encouraging continued mental rehearsal. The procedural skill of defibrillation can be taught pri- marily by repeated physical simulation, but the training program should also include a didactic component. This component will emphasize the extreme time-depen- dence of def ibrillation and will ai m to c ounter miscon- ceptions about defibrillation, particularly regarding safety issues for caregivers and patients [23]. This com- ponent can likely be mastered through self-study, with a text or computer-based tutorial. A study of the training program’seffectivenessshould be preceded by a p eriod for gathering baseline data on times to first monitoring and first defibrillation, [16] in order to gauge any Hawthorne effect in the subsequent study. A prospective, controlled study can be conducted by recruiting trainees to achieve randomization across shifts and units, so that any given unit will be staffed with a trained nurse approximately half of the time. If mean times to defibrillation are shortened in the experi- mental group (arrests with a defibrillation-trained nurse on the unit), survival can be tracked in a longer and/or larger study. The proporti on of successful defibrillations should increase, and the number of shockable rhythms should also increase due to earlier monitoring–before deterioration to asystole [25]. If the program proves effective, hospital-wide imple- mentation can be accomplished by training perhaps one-fourth to one-third of nurses. Full coverage can be ensured with a backup system if the hospital pages codes overhead or if all defibrillation-trained nurses carry code pagers, thus allowing them to respond to code calls on adjoining units (and leave if coverage is already in place). Likewise, defibrillation-trained nurses can be in structed to return to their routine duties after the code team arrives. Conclusions The link between early defibrillation and survival is beyond dispute. A progr am focused on early defibrilla- tion by nurses can be relatively easy to implement and cost-effective, and holds the promise of saving many lives. Competing interests The author declares that he has no competing interests. Received: 9 June 2010 Accepted: 29 July 2010 Published: 29 July 2010 References 1. Peberdy MA, Kaye W, Ornato JP, for the NRCPR Investigators, et al: Cardiopulmonary resuscitation of adults in the hospital: A report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003, 58:297-308. 2. Ehlenbach WJ, Barnato AE, Curtis JR, et al: Epidemiologic study of in- hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009, 361(1):22-31. 3. Andréasson AC, Herlitz J, Bång A, et al: Characteristics and outcome among patients with a suspected in-hospital cardiac arrest. Resuscitation 1998, 39(1):23-31. 4. Burns JP, Edwards J, Johnson J, et al: Do-not-resuscitate order after 25 years. Crit Care Med 2003, 31:1543-1550. 5. Hillman K, Parr M, Flabouris A, Bishop G, Stewart A: Redefining in-hospital resuscitation: The concept of the medical emergency team. 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Lloyd MS, Heeke B, Walter PF, Langberg JJ: Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation 2008, 117:2510-2514. 23. Mäkinen M, Niemi-Murola L, Kaila M, Castrén M: Nurses’ attitudes towards resuscitation and national resuscitation guidelines–Nurses hesitate to start CPR-D. Resuscitation 2009, 80:1399-1404. 24. Marsch SCU, Tschan F, Semmer N, et al: Performance of first responders in simulated cardiac arrests. Crit Care Med 2005, 33:963-967. 25. Weil MH: Rhythms and outcomes of cardiac arrest. Crit Care Med 2010, 38:310. doi:10.1186/1757-7241-18-42 Cite this article as: Stewart: Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010 18:42. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Stewart Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:42 http://www.sjtrem.com/content/18/1/42 Page 4 of 4 . M E N T AR Y Open Access Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest John A Stewart Abstract Time to first. cost-effective strategy to improve survival from in-hospital cardiac arrest. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010 18:42. Submit your next manuscript to BioMed Central and. program may be the best single strategy to improve in-hospital survival, simply and at reasonable cost. Introduction Survival from in-hospital cardiac arrest has not improved over the half-centur